<!DOCTYPE html>
<html>
  <head>
    <meta charset="UTF-8">
    <title></title>
  </head>
  <body>
    <form action="http://www.google.com/" method="post">
      <label for="tl">Title:</label> <input type="text" id="tl"><br>
      <label for="fn">First name:</label> <input type="text" id="fn"><br>
      <label for="ln">Last name:</label> <input type="text" id="ln"><br>
      <label for="cm">Company Name:</label> <input type="text" id="cm"><br>
      <label for="a1">Address line 1:</label> <input type="text" id="a1"><br>
      <label for="a2">Address line 2:</label> <input type="text" id="a2"><br>
      <label for="ct">City:</label> <input type="text" id="ct"><br>
      <label for="zc">Zip Code:</label> <input type="text" id="zc"><br>
      <label for="st">State:</label> <input type="text" id="st"><br>
      <label for="em">Email:</label> <input type="text" id="em"><br>
      <label for="ph">Phone Number:</label> <input type="text" id="ph"><br>
      <label for="c1">Name on card:</label> <input type="text" id="c1"><br>
      <label for="c2">Card Number:</label> <input type="text" id="c2"><br>
      <label for="c3">Expiration Month:</label> <input type="text" id="c3"><br>
      <label for="c4">Expiration Year:</label> <input type="text" id="c4"><br>
    </form>
  </body>
</html>
